HHS’s essential health benefits bulletin is less than two months old—in fact, the comment period just closed this week, click here for our comment letter—but some states are already planning for what it could mean for their residents.

The Bulletin indicates that states will be able to choose the core of their essential health benefits package by copying the benefits from one of ten existing health plans. That immediately raises the question—what do those ten plans cover? And which one would be best for kids, families, and all health insurance consumers?

Answering these questions will be complex, but a great way to start is to look at the ten plan choices side-by-side to compare what they cover. In Maine, the Department of Insurance has put together a helpful table that compares coverage across plans in some key benefit categories. It’s by no means a complete analysis, but it’s a great way to begin this important comparison.

Have you seen a similar document in your state? If not, it could be something to ask your state’s insurance regulator to put together. Of course, you’ll still want to make sure that the full plan documents that provide detailed coverage information are released publicly for each of the potential benchmarks before your state’s selection is made. But getting the plan comparison underway with a summary table like Maine’s can be a good way to get started—the Bulletin says states should choose their benchmark plans by the third quarter of this year.

– Joe Touschner
Georgetown University Center for Children and Families 

Fortunately, many advocates are already speaking up. Disability advocates from across the country have come together to produce a set of national advocacy principles to help guide their colleagues. The principles stress the importance of robust community-based long-term supportive services, such as help with daily activities including eating, bathing and dressing, managing medication, maintaining a residence, managing money, and getting out and about. These services are critical to enabling people to stay healthy, live well and maximize their independence.

The principles also emphasize consumer protections and control, and have broad applicability to work on Medicaid managed care and services for dually eligible seniors as well as people with disabilities. The principles are a joint effort of the Disability Rights and Education Defense Fund, the National Council on Independent Living, Tri-County Independent Living Center of Utah, Boston Center for Independent Living and Community Catalyst.

The principles are largely grounded in ongoing advocacy in Massachusetts, which has released its detailed draft proposal for the initiative, becoming the first of 15 states with federal planning grants to do so. Massachusetts disability advocates have testified at public hearings and submitted comments that are helping to shape the final plan. They have also issued specific suggestions on long-term supportive services.

Now is the time for advocates to get involved in all the states that are working on similar changes. Besides Massachusetts, the states that received federal planning grants are California, Connecticut, Colorado, Michigan, Minnesota, North Carolina, New York, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin More information on their initial plans can be found here. They are expected to submit detailed proposals to the federal Centers for Medicare & Medicaid Services this spring.

In total, 39 states are exploring new ways to finance care for people who are enrolled in both Medicaid and Medicare. You can find out if your state is involved by checking this list.

Please stay tuned for more news and resources.

–Alice Dembner, Deputy Policy Director

School Nutrition Standards: Would You Like (Sweet Potato) Fries with That?

First Lady Michelle Obama and Agriculture Secretary Tom Vilsack unveiled the new standards for school meals on January 25 in the form of a final rule, marking the first substantial changes to school meals in 15 years. The standards, a product of the Healthy, Hunger-Free Kids Act of 2010, have drawn significant public attention. People have strong feelings about school meals, as evidenced by the nearly 132,000 public comments the United States Department of Agriculture (USDA) received on the issue.

On the whole, the new standards promise to significantly improve the nutritional value of meals served in schools. Some positive developments in the final rule include:

• • An increase in the amounts of fruits and vegetables served every day
• • An increase in the amount of whole grains served
• • A requirement to provide only no- and low-fat milk options
• • A requirement to reduce the amounts of sodium, trans fat and saturated fat
• • A requirement to focus portion sizes to reflect appropriate calorie amounts for children based on age

Despite these positive improvements, some important provisions were removed from the initial proposed rule (after Congress required this), which is disappointing. These include limiting the USDA’s ability to regulate the amount of starchy vegetables provided in school lunches as well as preventing the USDA from increasing the amount of tomato paste required in order to allow it to count as a vegetable serving within the new framework.

These changes will have a significant impact, as nearly 32 million children participate in school meal programs every day. The new standards will be phased in over a three-year period, starting in the 2012 to 2013 school year. To see what a sample elementary school lunch menu could look like both before and after the new standards take effect, click here.

Voluntary Food Marketing Principles: Further Setbacks or Ronald McDonald is Here to Stay

On a less positive note, important progress toward the development of voluntary principles for marketing food to children came to a standstill at the end of 2011. The voluntary guidelines, developed by an Interagency Working Group (or IWG, consisting of the Federal Trade Commission, Food and Drug Administration, Centers for Disease Control and Prevention, and USDA) have received enormous criticism from the food and beverage industry. Initial opposition to the voluntary guidelines in October resulted in a narrowing focus to reduce advertising targeted at children under the age of 12 rather than all children under the age of 17 and provided exemptions for holiday promotions and established marketing characters. Further setbacks occurred in December when Congress required the IWG to conduct a cost-benefit analysis of the proposed guidelines, significantly delaying finalization of the proposal. At this stage, the ultimate fate of the guidelines remains unclear at best.

New Article Adds Further Evidence to Support Taxation of Sugar-Sweetened Beverages

A new article published in Health Affairs adds to the overwhelming evidence that supports the idea of SSB excise taxes as a key public health measure aimed at addressing obesity. The study authors found that a penny-per-ounce excise tax on SSBs would reduce SSB consumption by 15 percent for adults ages 25 to 64 and a 1.5 percent reduction in obese adults as a result. From 2010 to 2020, the study projected that this decrease in consumption would prevent 26,000 premature deaths while avoiding over $17 billion in medical expenses. While this study focused on adults, it’s consistent with a previous report by the USDA that has demonstrated the similarly positive health benefits for both children and adults resulting from SSB excise taxes.

It’s exciting that addressing child health through nutrition policy is being seen as a major priority. Now, it’s up to child health advocates to continue to educate policymakers about the importance of this issue to keep it front and center amidst a range of competing priorities in the coming months.

—Patrick M. Tigue, Senior Policy Analyst and
Kyle Bogaert, Intern, New England Alliance for Children’s Health

It’s obvious that spending lots of money on health care is not resulting in better health. Why is this so? One key reason is that the United States spends far less than many other countries on the many other factors that affect our HEALTH. Research consistently shows that people’s health is deeply influenced by their jobs, their income, educational opportunities and the social support their families can draw upon. According to a recent study published by Yale’s Global Health Institute, that was cited in The New York Times, the U.S. trails far behind other industrialized countries in its per capital expenditures on social services that can extend and improve life, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support, etc. So when you total the amount spent on health care and social services, the U.S. falls to 10th. And, as noted above, much of this spending is on health care not on other key approaches to improve health.

This is why health and public health advocates, as well as community members and policymakers, are joining together to improve how people live, learn, work and play as a means of achieving better health. We are forming partnerships in states and communities to increase access to education, secure jobs, community safety and other dimensions that improve lives and health. On the federal level, we are joining the fight to protect prevention funding in the Affordable Care Act from ‘raids’ to cover other budget items. We are expanding our sights and expanding our partners to improve health care and to improve HEALTH.

– Deborah Katz, Associate Director
Roadmaps to Health: Community Grants

Paying Pharmacies Honest Prices for Prescription Drugs

As policymakers across the country look to balance their budgets, some are turning to Medicaid, recycling the same harmful policies they’ve used year-after-year: eliminating coverage for vulnerable Americans, restricting critical benefits like prescription drug coverage, imposing premiums on those who can’t afford them, and slashing already-low provider reimbursement rates.

Community Catalyst and Georgetown University Health Policy Institute Center for Children and Families created the States of Innovation blog series to shine a spotlight on states that are trying to find a better way. We will highlight states that are pioneering new approaches to making Medicaid more sustainable without harming – and often by improving – care for the millions of vulnerable seniors, people with disabilities, children and low-income parents that rely on Medicaid.

The state of Alabama has pioneered a way to save millions of dollars in its Medicaid program by changing how it pays pharmacies for the drugs they provide to Medicaid patients.

Like 40 other states, Alabama used to reimburse pharmacies based on a pricing benchmark generated by prescription drug manufacturers, called Average Wholesale Price (AWP).

But documents made public in court cases have shown that drug manufacturers and others sometimes inflate their AWP list prices to incentivize pharmacies to buy their drugs. The manufacturers actually charge the pharmacy less than the published list price that Medicaid uses to reimburse the pharmacy for the drugs. For example, in Massachusetts from 1995 to 2003 the drug maker Warrick reported widely inflated list prices for an albuterol drug that was nearly seven-times the actual sales price. The pharmacies often reap a profit from this price “spread.”

Use of inaccurate, sometimes almost fictional list prices like AWP has led not only to overpayment but to outright fraud when companies lure pharmacies into favoring their products over competitors by increasing the profit margin. As a result of litigation on such pricing fraud, the main publisher of the AWP list (First Databank) ceased publishing it in September, 2011. However, this list price continues to be published by others, and as of now, 40 states and many private health plans continue to use this or other manufacturer generated list prices.

Alabama paves the way for a fairer – and more cost-effective – system

Alabama recently began reimbursing pharmacies based on an “evidence-based” benchmark, called Average Acquisition Cost (AAC.) It is based on an ongoing average of actual invoices of pharmacy purchases from drug manufacturers and wholesalers, which best reveals the actual cost of the drugs to the purchasing pharmacies. A dispensing fee is also paid to the pharmacy to cover the cost of pharmacist services and overhead.

Alabama’s Medicaid program has projected a 6.1 percent savings on its fee-for-service drug expenditures — that amounts to $30 million in the first year –without affecting prescription drug benefits provided to Medicaid beneficiaries or impacting quality of care. Indeed, the president of the Medical Society of the State of Alabama affirmed that changing to AAC should not affect patients’ access to care.

Three other states have followed Alabama’s lead: Oregon has implemented AAC pricing and expects to save $1.6 million, or 1 percent of its $160 million fee-for-service Medicaid drug expenditures. Idaho is in the process of implementing AAC, and expects to save $2 million in state general funds. And California has authorized a shift to AAC pricing as well.

CMS itself has also begun collecting drug cost data from pharmacy invoices nationally in order to assist states in evaluating their current payments systems. If CMS shares such information, it could help reduce the implementation costs to states, since they may not have to collect their own invoice data.

Private sector benefit

Alabama’s drug price information is available online here, and Oregon’s is published here. By making these regularly audited drug prices available to the public, these states and CMS can also make it easier for private insurance plans to adopt AAC and reduce their costs. Private plans will also be selling their products through the Affordable Care Act mandated Exchanges, often to low-income people not eligible for Medicaid or employer coverage. Since lowering pharmaceutical costs could help play a role in controlling premium costs, this would be of particular benefit to these low-income purchasers, and to the government, which will pay a sliding scale percentage of their premiums.

Pharmacy resistance

Some pharmacies have fought AAC pricing, claiming they cannot survive without the “spread” between what they paid for the drug and what they’re reimbursed from Medicaid. However, as court documents have revealed, many have been overpaid for years in a system with no transparency. If pharmacies were transparent about their actual cost of doing business—something they typically resist—and they could prove actual losses, the per-prescription dispensing fee Medicaid pays could be increased to cover those costs.

To find out more, see the AAC section of Community Catalyst’s new Medicaid Report Card.

]]> http://blog.communitycatalyst.org/index.php/2012/01/06/states-of-innovation-3/feed/ 0 http://blog.communitycatalyst.org/index.php/2012/01/05/oh-so-close%e2%80%a6/ http://blog.communitycatalyst.org/index.php/2012/01/05/oh-so-close%e2%80%a6/#comments Thu, 05 Jan 2012 16:39:45 +0000 admin http://blog.communitycatalyst.org/?p=2168 While the New England states are leaders in the nation in reducing the number of uninsured children, with coverage rates from 94 to 98 percent across the region, there is one area where New England is falling woefully behind. According to a new report from the Center on Budget and Policy Priorities only half the New England states, Maine, New Hampshire and Vermont, offer online applications and renewals for families trying to enroll their children in Medicaid or CHIP. This places the region squarely behind other parts of the country including the South and Northwest. With online applications available for everything from credit cards to colleges, it seems hard to believe that applications for vital health services are not available on such an efficient and accessible platform.

Many families live in rural areas without easy access to local government offices. These families would benefit from the remote access offered by online applications. Making applications available online would also reduce the potential for incomplete and misplaced submissions. Through questions, prompts and blocks that do not allow incomplete forms to be submitted, online applications provide useful feedback in a way paper applications cannot.

Given the high tech business sector in many New England states and with all the efforts states have put into achieving such high enrollment numbers, it is surprising that they have not taken advantage of this common-sense extra push. Online applications, along with other streamlined application and renewal procedures may be just what New England needs to get to 100 percent enrollment of eligible children in health coverage. Hopefully New England will make 2012 a year of great advances in coverage and consumer access starting with online applications and renewal for health benefits.

– Nicole Tambouret, Project Director
New England Alliance for Children’ Health

Please note, this blog was updated to reflect Maine’s policy on electronic applications, which was not originally reflected in the report.

The MLR, or the proportion of a premium spent on medical claims vs. profit and administration, was a topic that previously interested only the wonkiest of health wonks. But this year it became a hot issue that moved thousands of consumers across the country to contact their insurance commissioners and demand greater transparency and understanding of how our premium dollars are spent. And in a surprising turn in early December, the U.S. Department of Health and Human Services released regulations on the MLR that kept one of the more controversial parts of the MLR, broker fees, as part of the calculation.

More recently, there were some significant state wins on retaining a strong MLR standard. Both Florida and Michigan insurance commissioners applied to “adjust” (read: reduce) the amount that insurers must spend on medical claims. After strong advocacy by state partners in FL and MI, the Center for Consumer Information and Insurance Oversight (CCIIO), the federal agency charged with deciding the MLR rule, denied both states’ requests to ease the MLR for insurers. The headline: consumer protections won out over insurers’ financial interests.

So what does this mean? One reason the MLR is a big deal is that if insurers do not actually meet the MLR standards, they must provide consumers with rebates, starting in 2012. This very tangible benefit of the ACA was improved by CCIIO’s recent decision to make these rebates tax-free, and to require notices to consumers detailing the amount of the rebate and health plan’s MLR along with an explanation of what it means. Stay tuned for more details from CCIIO on how those rebates will roll out. And for now, be thankful that the Affordable Care Act provided this valuable tool to help protect consumers.

– Christine Barber, Senior Policy Analyst

1. Modern Healthcare’s analysis of non-profit hospital tax reports shows, for the first time ever , what hospitals spend nationally on charity care, and
2. The IRS held firm on requiring non-profit hospitals to report how they’re complying with ACA requirements on charity care (financial assistance), billing and debt collection for tax year 2011.

Here’s how these pieces connect. Starting with Fiscal Year 2009 tax documents (specifically, Schedule H of Form 990), the IRS finally required hospitals to break down and report community benefit spending, including charity care. After the tax forms were submitted in 2010 and made their way to the not-for-profit service GuideStar, Modern Healthcare took the data and did a comprehensive analysis. It found that half the non-profit hospitals spent 1.52 percent or less of total expenses on charity care, and two-thirds of non-profit hospitals spent 2 percent or less on charity care. The median profit margin was 3.13 percent.

Those numbers—in the aggregate, at least—aren’t pretty. But they’re not the whole story, either. Yes, it’s true that hospitals can choose to spend their community benefit dollars in ways other than charity care, and that those dollars can be well-spent (see Following the Leaders: How Some Hospitals Use Community Benefit Programs to Address Health Equity). But with charity care numbers this low, and unemployment and uninsured rates so high, we have to wonder: are hospitals running their community benefit programs in a way that sidesteps the need for financial assistance in their communities?

Holly Lang, an advocate in Georgia, put the Modern Healthcare findings into context in a “Marketplace” segment on American Public Media, saying that in an experiment she did with 34 hospitals in Georgia last summer, only two provided information about charity care (also called financial assistance) for uninsured patients. Clearly, there is room for improvement in the ways hospitals communicate with patients who need financial help. And we think improvement is on the horizon.

Last week, the IRS announced that, come Tax Year 2011, non-profit hospitals will have to report how they’re complying with new ACA requirements that deal with how hospitals run key parts of their community benefit programs, not just how much they spend. For example, non-profit hospitals will have to report on the contents of their financial assistance policies, including the steps they take to publicize them to the community—just the kind of information Lang found to be in short supply in Georgia last year.

This is an important step. Additional reporting will provide the data necessary for communities to assess their hospitals’ contributions to the community in a broader context than the charity care figures provided on 2009 documents, by including details about the financial assistance policy eligibility criteria, dissemination of the policy, and billing and collections practices. The data will also be crucial to inform further public policymaking.

Will everyone be pleased with these changes? Probably not. The IRS issued a 2010 Schedule H that reflected the requirements of the ACA. But, after pressure from the American Hospital Association and others, the IRS decided to make the reporting optional for 2010. (See our previous blog, Two Steps Forward, One Step Back on Hospital Transparency.)

But we’re glad the IRS has beefed up reporting. We need information about hospital spending and the particulars of key community benefit programs to understand how hospitals meet community needs, and where there’s room for improvement. At the end of the day, we believe transparency and sunshine will drive real change. So the next time Lang has an uninsured patient who needs hospital care in Georgia, we hope more than two provide life-saving information about charity care. Now let’s schedule that follow-up appointment…

– Anna Dunbar-Hester, Policy Analyst

At this point, with the Senate adjourned and the House rejecting the short-term extension, it is hard to see how the issue will get resolved. However, in a year that has featured several near shut-downs of government and routine 11th hour legislating, we can’t discount the possibility that some agreement will be reached. Still, it can’t be taken for granted that Congress will pull yet another rabbit out of its hat, and the cost of failure, in health care terms, will be high.

Although the most high profile health issue in the debate is preventing a 27 percent cut in the Medicare physician fee schedule, there are other important provisions at risk, including an extension of the “QI” program, which pays the Medicare Part B premium for low-income Medicare beneficiaries, and Transitional Medical Assistance, which allows families who would lose Medicaid eligibility as a result of an increase in earnings to temporarily retain that coverage. But the problem doesn’t stop there.

A failure to extend unemployment benefits and the payroll tax cut will have significant consequences for health care. First, at least some people losing unemployment insurance will end up on Medicaid, increasing the cost of that program as states struggle to recover from the recession and replace the lost federal Medicaid funds. Secondly, taking the purchasing power of unemployment benefits and the payroll tax cut out of the economy will be a drag on employment and will translate into further increases in the number of uninsured and people on Medicaid.

So what we are faced with is yet another example of Speaker Boehner and the House Republican caucus electing to play chicken, placing important health care programs and our fragile economic recovery at risk. This has become something of a pattern ever since they threatened to force a default on U.S. government debt earlier this year. Unfortunately, chicken is a risky game that often results in someone getting hurt.

– Michael Miller, Policy Director

The EHB is the floor, created in the Affordable Care Act (ACA), for what benefits many health plans will have to cover. It applies to all new health plans in the individual and small group markets beginning in 2014 (both those sold inside and outside Exchanges) as well as to Medicaid benchmark coverage.

The bulletin is relatively short but jam-packed with consequence. Instead of creating one national standard or even a national minimum benefit package, the bulletin allows each state, within certain parameters, to adopt their own definition of the EHB. States must benchmark their EHB to one of four existing health plan options. Let’s do the math—I believe that’s potentially 50 different EHBs nationwide (not exactly the national floor we hoped for)! But, in the holiday spirit, let’s shelve the sarcasm for a moment and review what the bulletin is, and what it’s not.

Laying Out the Benchmark Options
HHS will allow states to choose: (1) any of the three largest Federal Employees Health Benefits Program (FEHBP) plans by enrollment, (2) any of the three largest state employee health benefit plans by enrollment, (3) the largest plan by enrollment in any of the three largest small group insurance products offered in the state, or (4) the largest commercial non-Medicaid Health Maintenance Organization (HMO) plan in the state. The bulletin argues that the scope of benefits in small group plans tend to be in line with the federal and state employee plans and the largest non-Medicaid HMO plan, noting that these plans “do not differ significantly in the range of services they cover.”

Additionally, HHS also notes that the “largest plan by enrollment in the largest product in the State’s small group market” is the “default benchmark plan for the State” in event a state does not elect to choose an EHB benchmark. A reasonable assumption is that what this really means is that a federal Exchange operating in a state would use the default benchmark plan as the EHB. However, because the EHB applies not only to individual and small group plans sold through Exchanges but those sold in the outside market as well, this raises the question of whether HHS is really willing (or able) to impose the default benchmark plan on the outside market (as seems to be required by the ACA).

• • What it is: A benchmark plan approach to setting benefits.
• • What it’s not: A premium target approach, as recommended by the Institute of Medicine. HHS specifically states that the goal of the bulletin is to instruct states on how to model their scope of benefits — it does not address cost sharing or actuarial value in any way.

States Keep Their Mandates, for Now
State benefit mandates are a concern for state advocates and state officials from both a comprehensiveness of coverage and a cost perspective; the bulletin gives mandates a grace period. The ACA requires the states to defray the costs of any state mandates beyond the EHB package—a potentially significant problem for mandates that advocates want to preserve. Under the bulletin, however, if a state chooses a benchmark plan as the EHB that includes their state mandates (e.g., one of the small group plan options), they do not have to cover the cost of the mandates. However, if they choose an option not required to offer state mandates (e.g., one of the FEHBP plan options), a state does have to cover the cost of those mandates.

Essentially, this is a powerful incentive for states to choose one of the small group plan options for at least 2014 and 2015 as well as an incentive for states to eliminate their mandates during those two years. This is because the bulletin notes that in 2016 this issue will be revisited and states may not continue to be given an option to include their states as part of the EHB without bearing the cost for these benefits.

• • What it is: A delaying tactic on the mandate problem. Advocates will need to work hard over the next two years to secure the future of key mandates at both the federal and state levels.
• • What it’s not: Any kind of resolution on mandates. The guidance punts any final decision on this by HHS to 2016.

What About Those 10 Categories?
The statute demands that the EHB provide benefits across ten categories: (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. Of note, the statute also demands that the EHB be balanced across these ten categories, reflecting coverage found in a “typical employer plan.”

If you peg benefit scope to one of the small group plan options, are all 10 categories covered? HHS says, essentially, “yes . . . well mostly . . . well . . . we hope so.” The bulletin makes clear that HHS struggled to define what is “typical,” noting that if categories are missing from the benchmark they nevertheless must be included, using benefits from any other benchmark option. However, HHS remains uncertain as to how to supplement missing categories that are not traditionally covered, citing habilitative care and pediatric oral and vision care as particular issues.

• • What it is: A balancing act. Categories are filled by services offered in existing plans, leaving potential gaps in some benefits. The bulletin signals that any additional services will be based on other plans that cover those additional categories.
• • What it’s not: A clear method to fill in and balance the benefit categories. The specificity that consumer advocates hoped for is absent from the bulletin.

HHS Gives the Gift of Flexibility Not Just to States but to Insurers
As explained above, the bulletin will allow states to modify plans to reflect the 10 categories. But, in addition, the bulletin gives insurers a lot of wiggle room, saying that insurer flexibility promotes innovation. HHS notes in the bulletin that it is considering whether or not substitution may occur by insurers within and across EHB benefit categories and whether substitution across categories requires a “higher level of scrutiny.” Indeed, it does.

Due to the ability of states to choose their own benchmark plan, there will be inevitably be EHB variation across states. By also allowing modifications of plans by insurers within states, there will likely be additional variation among plans with respect to numerical limits, when a type of treatment would be approved, and the availability of particular drugs.

This is troubling on two fronts. First, it undermines the ability for consumers to make apples to apples comparisons across plans. Second, it can lead to discrimination against consumers with some health conditions. In other words, insurers may substitute some services that are needed by someone with a more costly health condition with services that woo healthier consumers.

• • What it is: Potentially, a high level of health plan variation.
• • What it’s not: A way to empower consumers to compare plans. The potential substitution allowance by HHS is risky—and without a clear monitoring plan, may put at risk necessary covered benefits for vulnerable consumers.

Is There Anything Else Under the Tree?
It doesn’t seem there’s a secret gift waiting for consumers in the bulletin that hasn’t been noticed yet, but the good news is that some of the more troubling aspects of the bulletin are “under consideration.” However, the general approach is unlikely to change. How this turns out now depends on getting HHS to at least modify its approach in a more positive direction as well as on how robust existing state plans are and which plans states choose. And all of this ultimately means that advocates need to voice their concerns at both federal and state levels as we move forward. The short-term opportunity for this is to submit comments to HHS on the bulletin by January 31, 2012 to essentialhealthbenefits@cms.hhs.gov.

—Eva Marie Stahl, Policy Analyst